Apgli Refund Form (other Than Death Claim) 5k384h
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¯èþÐèþ’¯é ¯ðþ™. 12 FORM No. 12
ÁÐèþ’ÔéQ yðþ”ÆðÿMæütÆóÿr, B™É«æþÉ糧óþÔý, òß”§æþÆé»ê§æþ. DIRECTORATE OF INSURANCE :: ANDHRA PRADESH :: HYDERABAD
ÁÐèþ’ÔéQ ɴ뙡Äèÿ yìþ糓Åsîü yðþ”ÆðÿMæütÆæÿ MéÆéÅËÄèÿÐèþ ____________________________________________ OFFICE OF REGIONAL DEPUTY DIRECTOR OF INSURANCE _________________________
¯èþÐèþ’¯é ¯ðþ™. 1 FORM NO.1 ÁÐèþ’ ÔéQ yðþ”ÆðÿMæütÆóÿr MéÆéÅËÄèÿ™, òߔɧé»ê§æþ ¯èþ™yìþ Ððþ€èþ¢™ Ðéç³çÜMøÆæÿ€èþ¯èþ²sìüt «æþÆæÿRêçÜ¢ (©°° ^èþ™§é§éÆæÿ 糓Ǣ ^óþÄèÿ’Í) APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE :: HYDERABAD (To be filled by the subscriber)
1.
2.
3.
^èþ™§é§éÆæÿ õ³Ææÿ, A€èþ° €èþ™Éyìþõ³Ææÿ, çßø§é
:
Subscriber's name and name of his father and designation
:
^èþ™§é§éÆæÿ çÜÈÓçÜ _ÐèþÇ ÆøkËÌø ç³°^óþíܯèþ MéÆéÅËÄèÿÐèþ õ³Ææÿ, hÌêÏ õ³Ææÿ
:
Name of the office and the District where the subscriber was last in service
:
^èþ™§é§éÆæÿ° ´ëËïÜ, Ìôý§é ´ëËïÜË ¯ðþ™ºÆæÿ, Ðésìü Ðésìü Ððþ€é¢Ë Ìôý§é A€èþ° É´ëÑyðþ™rç·™yæþ çÜ¿æýÅyðþ”¯èþrÏÆÿ€ôþ, ÇhçÙtÆæÿ ¯ðþ™. Number of policy or policies and their respective amounts or number of the subscriber if he was a member of theProvident Fund.
4.
´ëËïÜ Ððþ^èþÅÇsîü €ôþ¨
:
Date of Maturity of the Policy
:
5.
6.
G)
çÜÈÓçÜ çÜÐèþ’ç³¢Ððþ”¯èþ €ôþ¨:
a)
Date of termination of service
¼)
Éï³ÑÄèÿ™ Ððþ€é¢°² ÐèþçÜ’Ë ^óþíܯèþ _ÐèþÇ ¯ðþË
b)
Month of last deduction of
D Ððþ€é¢°² 55/58 çÜ™Ðèþ€èþÞÆéË ÐèþÄèÿçÜÞ ç³“Ç¢ MéN™yé¯óþ MóüÏÆÿÐèþ ^óþçÜ¢¯é²Æé? Is the amount being claimed before the completion of age 55/58
7.
D Ððþ€èþ¢™ ^ðþÍϙ糑 MøÆæÿ€èþ¯èþ²sìüt B™É«æþÉ糧óþÔý É糿æý€èþÓ ÉsðüfÈ õ³Ææÿ Ìôý§é õÜtsü »êÅ™Mü BŽ· òß”§æþÆé»ê§þ Ìôý§é õÜtsü »êÅ™Mü BŽ· C™yìþÄèÿ’ É»ê™_ õ³Ææÿ
:
Name of the Andhra Pradesh Government Treasury or the Branch of the State bank of Hyderabad or State Bank of India from which payment is desired.
8.
^èþ™§é§éÆæÿ _ÐèþÇ (5) HâèýÏ ç³°^óþíܯèþ MéÆéÅËÄèÿ™ õ³Ææÿ: Office in which the subscriber has worked during the last (5) years
9.
§æþÆæÿRêçÜ¢§éÆæÿ 糓Ǣ _Ææÿ¯éÐèþ’ Full address of the Applicant
10) G)
Ææÿ’. ..................................... H.í³.h.GÌý.I. ¯èþ™yìþ º}ý™ ´÷™¨Ðæþ‘¯é²Ææÿ. D Ððþ€é¢°Mìü Vé¯èþ’, Ææÿ’. .............................. ^ðþÍÏ™^èþÐèþËíÜ Ðæþ‘¯èþ²¨. D Ððþ€é¢°² Ðèþyîþz€ø çÜà ¯é ´ëËïÜ Ððþ€èþ¢™ ¯èþ™yìþ ÐèþçÜ’Ë ^óþçÜMö^èþa¯èþ. I have obtained A.P.G.L.I. Loan of Rs. ____________________ , out of which I have to pay Rs. ______________________ which may be recovered alongwith interest from my policy amount.
¼)
H§ðþ”¯é A¬Mæü Ððþ€èþ¢™ ´÷Ææÿ´ër¯èþ ^ðþÍϙ糑 fÇW™§æþ° Ðèþ¯èþÙ§æþ Mæü¯èþVö°¯èþ 糄æþ™Ìø, Asìüt A¬Mæü Ððþ€é¢°² ÇW ^ðþÍÏ™^óþ™§æþN »ê«æþÅyæþ¯ðþ” Ðæþ‘¯é²¯èþ°, Asìüt Ððþ€é¢°² ÐéÆÿ§éËÌø ¯é ·í ™^èþ¯èþ ¯èþ™yìþ €èþWY™^èþMö¯óþ™§æþN ¯é Üç Ðèþð €ñþÍÄèÿgôýçÜ’¢ C™§æþÐèþ’Ë™Vé Éç³Mæüsìü™^èþ^èþ¯é²¯èþ. I do hereby declare that if in future it is found that any excess payment was made to me in advertantly, I shall be held responsible to repay such excess amount and given my consent for deduction of the same from my pension instalments.
€ôþ¨ : _____________
^èþ™§é§éÆæÿ çÜ™€èþMæü™
Date: _____________
Signature of Subscriber
ò³”¯èþ ^óþíܯèþ çÜ™€èþMæü™/Ðóþíܯèþ ^ör¯èþ ÉÐóþÍ Ðèþɧæþ × __________________________________________________ (€èþ™Éyìþ õ³Ææÿ) __________________________ Ðéǧæþ° «æþ–ÒMæüÇ™^èþyæþÐèþÆÿ™¨. This is to certify that the above signature thumb impression is of ____________________________________ S/o. _______________________________________
€ôþ¨ : Date:
«æþ–ÒMæüÇçÜ¢¯èþ² Vðühsðüyþ A¬MéÇ çÜ™€èþMæü™: Signature of the Certifying Gazetted Officer
MéÆéÅËÄèÿ Ðèþɧæþ OFFICE SEAL
A¬MéÇ õ³Ææÿ: Name of the Officer :
çßø§é: Designation:
Ææÿ’´ëÆÿ Æðÿѯèþ’Å Ýët™ç³‘ REVENUE STAMP 1 RUPEE
ÆæÿÖ§æþ RECEIPT
VæüÐèþ°Mæü: ò³”Mæü™ Ææÿ’. 500&00 ËN Ñ™_¯èþrÏÆÿ€ôþ D ÆæÿÖ§æþN Ýët™ç³‘ AMìü™^éÍ. Note: If the amount exceeds Rs. 500/- this receipt should be duly stamped.
¯ðþ™. VæüË ^èþ™§é§éÆæÿ ×/×Ðèþ ______________________________________________ ¡çÜMö¯èþ² ÁÐèþ’ Ððþ€èþ¢™/É´ëÑyðþ™sü ç·™yæþ Ððþ€èþ¢™/Ææÿ}ý™ Ððþ€èþ¢™/»ø¯èþŽÜ Ððþ€é¢ËN çÜ™º™¬™_¯èþ ÆæÿÖ§æþ. Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of Sri/Smt. ______________________ subscriber No. __________________
×/×Ðèþ ________________________________ AsêȲ/»ôýÆæÿÆÿ AÆÿ¯èþ ________________________ ¯óþ¯èþ iÑ€èþ ÁÐèþ’ ÔéQ yðþ”ÆðÿMæütÆóÿr, òߔɧé»ê§þ ÐéÇ ¯èþ™yìþ Ææÿ. ________________ (Ææÿ’´ëÄèÿË ________________ Ðèþ’É€èþÐóþ) €ôþ¨ ________________ €ôþ¨ ¯ðþ™. ________________ VæüË ^ðþNP / yìþ.yìþ. A™§æþMö¯èþ²rÏ C™§æþÐèþ’ËÐèþVé ÆæÿÖ§æþ A™§æþgôýçÜ¢¯é²Ææÿ. I, _________________________________ hereby acknowledge receipt of Rs. ____________ (Rupees ______________________ only) from the ____________ Directorate of Insurance, Hyderabad per self Sri/Smt. __________________ Attorney / Bearer for Cheque / D.D. No. ______________ Dated __________________ .
ò³”Mæü™ ¡çÜN¯èþ² Ðé° çÜ™€èþMæü™
´ëËïܧéÆæÿ / MæüÏÆÿÐèþ§éÆæÿ çÜ™€èþMæü™ €ôþyé »ör¯èþÉÐóþÍ Ðèþɧæþ
Signature of Receipient
Signature or thumb-impression of the policy holder/claimant
×/×Ðèþ ________________________ ^óþíܯèþ ò³” çÜ™€èþMæüÐèþ / ^ör¯èþÉÐóþÍ Ðèþɧæþ çÜÐèþ„æþÐèþÌø ^óþÔéÆæÿ° / ÐóþÔéÆæÿ° C™§æþÐèþ’Ë™Vé «æþ–Ðèþç³ÆæÿçÜ¢¯é²¯èþ. I hereby certify that the above signature / thumb impression of Sri / Smt. _________________________ is made in my presence.
Vðühsðüyþ A¬MéÇ õ³Ææÿ Name of the Gazetted Officer
çßø§é Designation
«æþ–ÒMæüÆæÿ}ý €ôþ¨: «æþ–ÒMæü–€èþ A¬MéÇ çÜ™€èþMæüÐèþ Date of attestation Signature of Certifying Officer
MéÆéÅËÄèÿ Ðèþɧæþ OFFICE SEAL × ________________________ çÜÐèþǵ™_¯èþ «æþ–Ðèþç³É€èþ™ B«éÆæÿ™Vé ò³” ^ðþNP¯èþ ÐèþÅMìü¢Væü€èþ™Vé A™§æþgôýÄèÿyæþÐèþÆÿ™¨. On the strength of certification of _____________________ the above cheque is delivered personally.
VæüÐèþÝë¢
çÜ’ç³Ç™sðü™yðþ™r
iÑ€èþ ÁÐèþ’ ÔéQ AíÜòÜt™r yðþ”ÆðÿMæütÆæÿ
Clerk
Superindent
Asst. Director of Insurance
ÁÐèþ’ÔéQ yðþ”ÆðÿMæütÆóÿr, B™É«æþÉ糧óþÔý, òß”§æþÆé»ê§æþ. DIRECTORATE OF INSURANCE :: ANDHRA PRADESH :: HYDERABAD
ÁÐèþ’ÔéQ ɴ뙡Äèÿ yìþ糓Åsîü yðþ”ÆðÿMæütÆæÿ MéÆéÅËÄèÿÐèþ ____________________________________________ OFFICE OF REGIONAL DEPUTY DIRECTOR OF INSURANCE _________________________
¯èþÐèþ’¯é ¯ðþ™. 1 FORM NO.1 ÁÐèþ’ ÔéQ yðþ”ÆðÿMæütÆóÿr MéÆéÅËÄèÿ™, òߔɧé»ê§æþ ¯èþ™yìþ Ððþ€èþ¢™ Ðéç³çÜMøÆæÿ€èþ¯èþ²sìüt «æþÆæÿRêçÜ¢ (©°° ^èþ™§é§éÆæÿ 糓Ǣ ^óþÄèÿ’Í) APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE :: HYDERABAD (To be filled by the subscriber)
1.
2.
3.
^èþ™§é§éÆæÿ õ³Ææÿ, A€èþ° €èþ™Éyìþõ³Ææÿ, çßø§é
:
Subscriber's name and name of his father and designation
:
^èþ™§é§éÆæÿ çÜÈÓçÜ _ÐèþÇ ÆøkËÌø ç³°^óþíܯèþ MéÆéÅËÄèÿÐèþ õ³Ææÿ, hÌêÏ õ³Ææÿ
:
Name of the office and the District where the subscriber was last in service
:
^èþ™§é§éÆæÿ° ´ëËïÜ, Ìôý§é ´ëËïÜË ¯ðþ™ºÆæÿ, Ðésìü Ðésìü Ððþ€é¢Ë Ìôý§é A€èþ° É´ëÑyðþ™rç·™yæþ çÜ¿æýÅyðþ”¯èþrÏÆÿ€ôþ, ÇhçÙtÆæÿ ¯ðþ™. Number of policy or policies and their respective amounts or number of the subscriber if he was a member of theProvident Fund.
4.
´ëËïÜ Ððþ^èþÅÇsîü €ôþ¨
:
Date of Maturity of the Policy
:
5.
6.
G)
çÜÈÓçÜ çÜÐèþ’ç³¢Ððþ”¯èþ €ôþ¨:
a)
Date of termination of service
¼)
Éï³ÑÄèÿ™ Ððþ€é¢°² ÐèþçÜ’Ë ^óþíܯèþ _ÐèþÇ ¯ðþË
b)
Month of last deduction of
D Ððþ€é¢°² 55/58 çÜ™Ðèþ€èþÞÆéË ÐèþÄèÿçÜÞ ç³“Ç¢ MéN™yé¯óþ MóüÏÆÿÐèþ ^óþçÜ¢¯é²Æé? Is the amount being claimed before the completion of age 55/58
7.
D Ððþ€èþ¢™ ^ðþÍϙ糑 MøÆæÿ€èþ¯èþ²sìüt B™É«æþÉ糧óþÔý É糿æý€èþÓ ÉsðüfÈ õ³Ææÿ Ìôý§é õÜtsü »êÅ™Mü BŽ· òß”§æþÆé»ê§þ Ìôý§é õÜtsü »êÅ™Mü BŽ· C™yìþÄèÿ’ É»ê™_ õ³Ææÿ
:
Name of the Andhra Pradesh Government Treasury or the Branch of the State bank of Hyderabad or State Bank of India from which payment is desired.
8.
^èþ™§é§éÆæÿ _ÐèþÇ (5) HâèýÏ ç³°^óþíܯèþ MéÆéÅËÄèÿ™ õ³Ææÿ: Office in which the subscriber has worked during the last (5) years
9.
§æþÆæÿRêçÜ¢§éÆæÿ 糓Ǣ _Ææÿ¯éÐèþ’ Full address of the Applicant
10) G)
Ææÿ’. ..................................... H.í³.h.GÌý.I. ¯èþ™yìþ º}ý™ ´÷™¨Ðæþ‘¯é²Ææÿ. D Ððþ€é¢°Mìü Vé¯èþ’, Ææÿ’. .............................. ^ðþÍÏ™^èþÐèþËíÜ Ðæþ‘¯èþ²¨. D Ððþ€é¢°² Ðèþyîþz€ø çÜà ¯é ´ëËïÜ Ððþ€èþ¢™ ¯èþ™yìþ ÐèþçÜ’Ë ^óþçÜMö^èþa¯èþ. I have obtained A.P.G.L.I. Loan of Rs. ____________________ , out of which I have to pay Rs. ______________________ which may be recovered alongwith interest from my policy amount.
¼)
H§ðþ”¯é A¬Mæü Ððþ€èþ¢™ ´÷Ææÿ´ër¯èþ ^ðþÍϙ糑 fÇW™§æþ° Ðèþ¯èþÙ§æþ Mæü¯èþVö°¯èþ 糄æþ™Ìø, Asìüt A¬Mæü Ððþ€é¢°² ÇW ^ðþÍÏ™^óþ™§æþN »ê«æþÅyæþ¯ðþ” Ðæþ‘¯é²¯èþ°, Asìüt Ððþ€é¢°² ÐéÆÿ§éËÌø ¯é ·í ™^èþ¯èþ ¯èþ™yìþ €èþWY™^èþMö¯óþ™§æþN ¯é Üç Ðèþð €ñþÍÄèÿgôýçÜ’¢ C™§æþÐèþ’Ë™Vé Éç³Mæüsìü™^èþ^èþ¯é²¯èþ. I do hereby declare that if in future it is found that any excess payment was made to me in advertantly, I shall be held responsible to repay such excess amount and given my consent for deduction of the same from my pension instalments.
€ôþ¨ : _____________
^èþ™§é§éÆæÿ çÜ™€èþMæü™
Date: _____________
Signature of Subscriber
ò³”¯èþ ^óþíܯèþ çÜ™€èþMæü™/Ðóþíܯèþ ^ör¯èþ ÉÐóþÍ Ðèþɧæþ × __________________________________________________ (€èþ™Éyìþ õ³Ææÿ) __________________________ Ðéǧæþ° «æþ–ÒMæüÇ™^èþyæþÐèþÆÿ™¨. This is to certify that the above signature thumb impression is of ____________________________________ S/o. _______________________________________
€ôþ¨ : Date:
«æþ–ÒMæüÇçÜ¢¯èþ² Vðühsðüyþ A¬MéÇ çÜ™€èþMæü™: Signature of the Certifying Gazetted Officer
MéÆéÅËÄèÿ Ðèþɧæþ OFFICE SEAL
A¬MéÇ õ³Ææÿ: Name of the Officer :
çßø§é: Designation:
Ææÿ’´ëÆÿ Æðÿѯèþ’Å Ýët™ç³‘ REVENUE STAMP 1 RUPEE
ÆæÿÖ§æþ RECEIPT
VæüÐèþ°Mæü: ò³”Mæü™ Ææÿ’. 500&00 ËN Ñ™_¯èþrÏÆÿ€ôþ D ÆæÿÖ§æþN Ýët™ç³‘ AMìü™^éÍ. Note: If the amount exceeds Rs. 500/- this receipt should be duly stamped.
¯ðþ™. VæüË ^èþ™§é§éÆæÿ ×/×Ðèþ ______________________________________________ ¡çÜMö¯èþ² ÁÐèþ’ Ððþ€èþ¢™/É´ëÑyðþ™sü ç·™yæþ Ððþ€èþ¢™/Ææÿ}ý™ Ððþ€èþ¢™/»ø¯èþŽÜ Ððþ€é¢ËN çÜ™º™¬™_¯èþ ÆæÿÖ§æþ. Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of Sri/Smt. ______________________ subscriber No. __________________
×/×Ðèþ ________________________________ AsêȲ/»ôýÆæÿÆÿ AÆÿ¯èþ ________________________ ¯óþ¯èþ iÑ€èþ ÁÐèþ’ ÔéQ yðþ”ÆðÿMæütÆóÿr, òߔɧé»ê§þ ÐéÇ ¯èþ™yìþ Ææÿ. ________________ (Ææÿ’´ëÄèÿË ________________ Ðèþ’É€èþÐóþ) €ôþ¨ ________________ €ôþ¨ ¯ðþ™. ________________ VæüË ^ðþNP / yìþ.yìþ. A™§æþMö¯èþ²rÏ C™§æþÐèþ’ËÐèþVé ÆæÿÖ§æþ A™§æþgôýçÜ¢¯é²Ææÿ. I, _________________________________ hereby acknowledge receipt of Rs. ____________ (Rupees ______________________ only) from the ____________ Directorate of Insurance, Hyderabad per self Sri/Smt. __________________ Attorney / Bearer for Cheque / D.D. No. ______________ Dated __________________ .
ò³”Mæü™ ¡çÜN¯èþ² Ðé° çÜ™€èþMæü™
´ëËïܧéÆæÿ / MæüÏÆÿÐèþ§éÆæÿ çÜ™€èþMæü™ €ôþyé »ör¯èþÉÐóþÍ Ðèþɧæþ
Signature of Receipient
Signature or thumb-impression of the policy holder/claimant
×/×Ðèþ ________________________ ^óþíܯèþ ò³” çÜ™€èþMæüÐèþ / ^ör¯èþÉÐóþÍ Ðèþɧæþ çÜÐèþ„æþÐèþÌø ^óþÔéÆæÿ° / ÐóþÔéÆæÿ° C™§æþÐèþ’Ë™Vé «æþ–Ðèþç³ÆæÿçÜ¢¯é²¯èþ. I hereby certify that the above signature / thumb impression of Sri / Smt. _________________________ is made in my presence.
Vðühsðüyþ A¬MéÇ õ³Ææÿ Name of the Gazetted Officer
çßø§é Designation
«æþ–ÒMæüÆæÿ}ý €ôþ¨: «æþ–ÒMæü–€èþ A¬MéÇ çÜ™€èþMæüÐèþ Date of attestation Signature of Certifying Officer
MéÆéÅËÄèÿ Ðèþɧæþ OFFICE SEAL × ________________________ çÜÐèþǵ™_¯èþ «æþ–Ðèþç³É€èþ™ B«éÆæÿ™Vé ò³” ^ðþNP¯èþ ÐèþÅMìü¢Væü€èþ™Vé A™§æþgôýÄèÿyæþÐèþÆÿ™¨. On the strength of certification of _____________________ the above cheque is delivered personally.
VæüÐèþÝë¢
çÜ’ç³Ç™sðü™yðþ™r
iÑ€èþ ÁÐèþ’ ÔéQ AíÜòÜt™r yðþ”ÆðÿMæütÆæÿ
Clerk
Superindent
Asst. Director of Insurance
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